Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sherbrooke Village during CMS and state inspections, most recent first.
Two residents did not receive adequate pain management in line with facility policy. One resident was admitted with a pelvic fracture and hospital discharge orders for multiple pain medications, yet no pharmacologic or non‑pharmacologic pain interventions were administered for many hours after admission, despite documented escalating pain up to 10/10 and descriptions of excruciating pain overnight. Medication orders for acetaminophen, hydromorphone, cyclobenzaprine, and gabapentin were present, but the MAR showed they were not given as ordered, and staff interviews revealed confusion about eKit use, lack of signed narcotic scripts, and failure to secure timely pain control. Another resident with a coccyx pressure ulcer reported significant pain during transfers and wound care, frequently yelling and moaning, while the care plan did not address wound‑related pain and PRN acetaminophen was never administered over multiple opportunities, with hydrocodone‑acetaminophen given inconsistently. CNAs and a CMT reported relaying pain complaints to nursing, but were unsure if pain medications were provided, and wound care had to be stopped due to uncontrolled pain.
Staff failed to consistently treat residents with dignity and to follow the facility’s cell phone policy. A cognitively intact resident with Parkinson’s disease, dementia, and COPD was denied requested assistance to the dining room and was told by a CNA to move using his/her feet despite visible discomfort, until another aide intervened. A resident with severe cognitive impairment and significant neurologic deficits was fed by a CNA who wore earbuds and looked at a cell phone during the meal. Other cognitively intact residents reported that staff frequently used cell phones and headphones in hallways and while providing care, and resident council members described staff turning off call lights while stating they were not the assigned aide, leaving without notifying others, and talking loudly or yelling on the halls at night. Observations and staff interviews confirmed that these actions conflicted with the facility’s stated expectations that residents be treated with respect and that personal cell phones and headphones not be used in resident care areas.
Surveyors found that hot foods were not maintained at the facility’s required temperature standard during observed meal services, with items such as soup, meatballs, cream of wheat, scrambled eggs, and biscuits and gravy all measuring below 135°F. Multiple cognitively intact residents, including individuals with COPD, dementia, quadriplegia, chronic kidney disease, heart failure, diabetes, depression, and anxiety, reported that their meals—especially room trays—were usually or always served cold. These findings conflicted with the stated expectations of the dietary supervisor, administrator, and DON that food be delivered at safe and palatable temperatures.
Two residents had wheelchairs with thick dust, food particles, and hair on the frames and wheels, and both said their wheelchairs had never been cleaned. Staff gave inconsistent accounts of wheelchair cleaning, with the LPN saying there was no schedule and the DON saying night shift was expected to clean them. The facility also left a large blood stain on a living room carpet for days and kept a pest control glue trap on tables in a common area, which staff said was not homelike.
The facility failed to send required transfer and discharge notices to the Ombudsman for most of the months reviewed. The SSD acknowledged missing months of notifications and said it was her responsibility to send the information, and the Administrator said she expected the SSD to provide the required discharge and transfer documentation.
Failure to Provide Resident Activities: A resident with severe cognitive impairment and care plan interventions for one-on-one room visits had only one brief documented interaction, while two cognitively intact residents reported that too few activities were offered and that many were babyish. Observations showed no activities on the 300 hall, and scheduled programs on [NAME] Hall did not occur as listed on the activity calendar. Staff and the DON confirmed activities were not being completed consistently, with the AD reporting short staffing and competing duties.
Multiple medication and treatment carts were found unlocked and cluttered with expired, unlabeled, and improperly stored medications and supplies. Surveyors observed open bottles and packages without dates, loose pills, unlabeled blister packs, expired needles and eye drops, and medication items stored with personal food items. An LPN and the ADON stated open meds without dates should be discarded, carts should not be left unlocked, and expired or loose medications should not remain on carts.
Staff failed to use proper infection control while feeding a resident with severe cognitive impairment and multiple neurologic diagnoses when a CNA blew on soup and meatballs before feeding them. The facility also failed to keep a steam table clean on [NAME] Hall; observations showed baked-on food, cloudy water with sediment, and crusted residue, and staff reported the steam tables had looked dirty for months.
A cognitively intact resident with Parkinson’s disease, dementia, COPD, and frequent bowel and bladder incontinence, who depended on staff for toileting hygiene, was left soiled and wet for an extended period despite calling out for help. The resident’s call light was wrapped around the bed frame and out of reach, and over more than two hours the resident remained in bed with a strong odor of stool and urine, repeatedly stating they were soiled and had not been checked. When a CNA and an LPN finally entered, they found the brief and bed pad saturated with urine and a large amount of diarrhea, contrary to the care plan and staff statements that incontinent residents should be checked every one to two hours and kept clean, dry, and odor free.
A resident with cognitive impairment, incontinence, and neurogenic bladder used a family-applied condom catheter at night for over a month without any physician orders, care plan interventions, or documented monitoring. Surveyors observed the drainage bag and tubing on the floor, with the condom catheter secured by duct tape. A CNA reported the family applied and removed the device and managed the drainage bag, while nursing staff, including LPNs and the DON, stated they were unaware of the device’s use and that no documentation, skin assessments, or monitoring of urinary output and characteristics had been completed.
Surveyors identified that the facility’s medication error rate exceeded 5%, based on three errors in 27 observed opportunities. A resident with dementia and hypotension received Midodrine without a BP check beforehand, and the CMT administering it did not know the drug’s purpose. Another resident with severe cognitive impairment and multiple comorbidities had two glaucoma eye drop medications ordered, but the care plan did not address the need for eye drops, and the CMT administered both ophthalmic solutions back-to-back without the required pause or proper technique, contrary to facility policy and manufacturer instructions.
Call Light Not Kept Within Resident Reach: A resident with Parkinson's disease, dementia, COPD, and frequent bowel and bladder incontinence was observed yelling for help, stating he/she needed the bathroom and could not reach the call light. Surveyors found the call light wrapped around the bed frame and later tucked between a recliner cushion and about two feet away from the resident, while the resident was also observed soiled and wet. CNA X, LPN K, and the DON stated the call light should be within reach at all times.
Failure to follow physician orders and medication administration standards: one resident with CHF, HTN, and renal failure did not receive ordered daily weights consistently, with staff saying night shift aides were responsible for obtaining and documenting them. In a separate event, a resident with severe cognitive impairment, Parkinson disease, diabetes, COPD, dysphagia, and multiple pressure ulcers had crushed meds left in a cup in the room for a family member to give, and the DON stated family members should never administer medications and staff should have remained at the bedside.
A resident with a coccyx wound had missed ordered treatments and worsening breakdown, another resident with multiple stage 3 and 4 pressure ulcers had saturated or dislodged dressings and a low air loss mattress set at a 500-lb setting despite weighing 117 lbs, and a third resident at high risk for skin breakdown had a mattress set to 320 with normal pressure without a physician order for the setting. The DON and wound nurse described gaps in monitoring mattress settings and following ordered wound care, while observations documented soiled bedding, compromised dressings, and ongoing wound drainage.
Failure to provide appropriate foot care for two residents. One resident with severe cognitive impairment and another resident with diabetes, Parkinson’s disease, dementia, and COPD were observed with extremely dry feet and overgrown toenails, while care plans did not address foot care and there were no podiatry consult orders or appointments listed. Staff interviews showed CNAs and LPNs were expected to identify foot issues, apply lotion, and arrange podiatry services as needed.
Failure to use a gait belt during a resident transfer. A resident with Parkinson's disease, dementia, COPD, and dependence for some ADLs required one-staff assist for transfers and used a wheelchair. During an observed bed-to-wheelchair transfer, a CNA and an LPN assisted the resident without a gait belt, instead holding the resident under an arm and by the pants while pivoting the resident into the wheelchair. The LPN acknowledged the gait belt should have been used, and the DON stated staff were expected to use gait belts for residents needing transfer assistance.
Inaccurate Documentation of Wound Care and Oxygen Tubing Change: Staff documented a resident’s wound care and oxygen tubing change as completed on the TAR even though observations showed the tubing and toe dressing were still dated from earlier times. The resident was cognitively intact with diagnoses including dementia, muscle weakness, and quadriplegia, and an LPN said the toe wound was healed but the dressing was being used preventatively. The Administrator said there was no policy on documentation accuracy, and the Administrator and DON stated treatments should not be documented as completed if they were not actually done.
CNA in-service training hours were not ensured for two sampled CNAs. The facility assessment listed annual competency topics such as dementia care, abuse prevention-related content, ADLs, and resident assessment, but did not identify the annual CNA training-hour requirement. One CNA completed 15.5 hours of training on the first day of survey, while another CNA completed only 3.5 hours over a year. CNA N, the DON, and the Administrator stated CNAs were expected to complete 12 hours of annual training through an online portal.
A resident with vascular dementia, COPD, and CKD experienced inadequate foot care, resulting in dry skin and a blister on the left foot. Despite physician orders for skin assessments and wound care, there were no orders for lotion or preventive ointments, and the care plan was not updated. Observations showed dry, flaky skin and a raw area on the left foot. Staff were aware of the issues but failed to document or treat the dry skin, and the facility's skin integrity policy was not followed.
A resident with a history of dementia and confusion was found with serious injuries, including a bloodied face, in a LTC facility. Despite the severity and unknown origin of the injuries, the facility failed to report the incident to DHSS within the required two-hour timeframe, assuming it was an unwitnessed fall.
The facility failed to maintain a licensed Administrator, leading to a gap in compliance with regulations. The DBO temporarily filled the role without a license after Administrator A's license expired, and efforts to contract a new Administrator were unsuccessful.
The facility failed to conduct NA registry checks for three out of ten sampled new hires, as required by their abuse prevention policy. Interviews revealed a lack of awareness about the necessity of these checks for non-nursing staff, potentially compromising resident safety.
The facility failed to provide bedtime snacks, offering them only mid-day between lunch and dinner. Residents reported not receiving snacks after dinner, with one experiencing low blood sugar at night. Snacks were stored in cabinets known only to staff, and there was uncertainty about their availability. The DON stated snacks should be available after dinner, but this was not ensured.
The facility failed to follow infection control practices, including not cleaning treatment carts between rooms and neglecting hand hygiene during wound care. Staff did not wear appropriate PPE during high-contact activities with residents on enhanced barrier precautions. These deficiencies were observed despite the facility's policies and expectations for infection control.
A resident with a surgical wound and low blood pressure experienced purulent drainage and elevated temperature, but the facility failed to notify the physician promptly. Despite documentation of the resident's condition, there was a lack of communication between shifts, leading to a delay in medical intervention. Interviews revealed inconsistencies in reporting practices, and the Director of Nursing expected immediate notification of the physician, which did not occur.
A facility failed to clarify medication orders, leading to duplicated doses for a resident with Alzheimer's and GERD. Additionally, another resident with a dehisced surgical incision was not sent to the hospital in a timely manner despite physician orders. Communication lapses and task delegation issues contributed to these deficiencies.
A facility failed to implement a stop date for a PRN psychotropic medication prescribed to a resident with impaired cognition and behaviors. The resident was given Lorazepam without a specified end date, contrary to the facility's policy requiring a 14-day stop date for PRN antianxiety medications. Interviews with the DON and administrator confirmed the oversight, revealing a deficiency in medication management practices.
The facility failed to properly label and store medications, as observed in a survey. An expired Pantoprazole suspension and an undated PPD vial were found in medication room refrigerators. Additionally, temperature logs for medication refrigerators were incomplete, with several missing entries and out-of-range temperatures. Staff interviews revealed lapses in responsibility for checking expired medications and logging temperatures.
The facility did not make the most recent survey and complaint investigation results accessible to residents and visitors. Observations showed no survey results at the entrance, lobby, or receptionist desk, and no signs indicating their location. Residents and staff were unaware of the binder's whereabouts, with suggestions it might be in storage due to lobby construction.
Failure to Provide Timely and Adequate Pain Management for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate pain management for two residents in accordance with its own pain management policy. For one resident with a recent pelvic fracture and history of intractable pain, the facility did not administer any pharmacologic or non‑pharmacologic pain interventions for approximately 20 hours after admission from the hospital, despite hospital discharge instructions that included multiple pain medications. The hospital’s After Visit Summary listed scheduled and PRN orders for acetaminophen, cyclobenzaprine, hydromorphone, and gabapentin, with the last doses given shortly before discharge. On admission, the RN documented the resident as alert and oriented with multiple fractures and chronic pain conditions, and noted that medications were verified with the in‑house NP, but only non‑pain‑related changes were made at that time. The electronic physician orders later reflected orders for Tylenol, hydromorphone, cyclobenzaprine, and gabapentin, yet the MAR showed that none of these pain medications were administered on the day of admission or the following day, except for a single gabapentin dose. Overnight, the resident’s pain escalated significantly. A skilled evaluation note documented a pain score of 4/10 with a notation that PRN medication was provided, but the MAR did not show any corresponding administration of ordered pain medications. Subsequent pain level summaries recorded the resident’s pain as 4/10 and then 10/10, and a nurse’s progress note described the resident as in excruciating pain, awake crying most of the night, and frequently using the call light for repositioning. The nurse contacted the on‑call provider about the increased pain and later documented that the NP recommended sending the resident back to the hospital for pain management. Interviews revealed that the admitting RN did not recall the resident complaining of pain and stated that narcotics could not be pulled from the eKit without signed scripts, and that residents needed to understand the facility would not have their pain medications immediately. The night RN stated that if Tylenol had been ordered it would have been given, but could not confirm administration and acknowledged that documentation should have reflected any Tylenol use. The pharmacy vendor reported having no record of the resident, and the DON stated she expected staff to verify medications, obtain signed scripts, and use available alternatives and non‑pharmacologic interventions, which were not documented as occurring. The second resident had a coccyx pressure ulcer and reported pain associated with this wound, but the facility did not consistently implement pain control interventions during wound care. The resident’s MDS showed occasional pain and multiple comorbidities, and physician orders included PRN hydrocodone‑acetaminophen and acetaminophen, along with a pain scale each shift. The care plan addressed risk for pressure ulcer development and skin integrity but did not address pain related to the existing coccyx pressure ulcer. MAR review showed that PRN acetaminophen was not administered for any of 14 possible opportunities, and hydrocodone‑acetaminophen was given only 8 of 12 possible times, including a dose earlier on the day of observation. During wound care and transfers, the resident repeatedly stated that it hurt and described multiple sore spots, yelling and moaning while being turned and while the wound was cleansed. Staff acknowledged that the resident complained of pain frequently and that they reported this to the nurse, but they were unsure whether pain medication was administered. Wound care had to be stopped due to the resident’s pain, and the Wound Nurse stated she would contact the provider for new pain management orders. The DON later stated she expected staff to address residents’ pain comments and administer medications as ordered, which did not occur consistently for this resident during wound treatment.
Failure to Maintain Resident Dignity and Enforce Cell Phone Restrictions
Penalty
Summary
The deficiency involves failure to honor residents’ rights to dignity and appropriate assistance, and failure to enforce the facility’s prohibition on staff use of personal cell phones in resident care areas. One cognitively intact resident with Parkinson’s disease, dementia, and COPD was observed in a wheelchair at the end of a hallway asking a CNA for help to get to the dining room. The CNA refused to push the resident because the wheelchair had no foot pedals, instructed the resident to move using his/her feet, and repeated this direction even as the resident only advanced a few feet and appeared uncomfortable. Another aide ultimately assisted the resident into the dining room. In later interviews, a CNA, an LPN, and facility leadership all stated that staff should assist residents when they ask for help and that residents should be treated and spoken to in a dignified manner. The report also documents multiple instances of staff using personal cell phones and headphones in resident care areas and during direct care, contrary to the facility’s written policy. A resident with severe cognitive impairment and multiple neurologic deficits was being fed in the dining room by a CNA who had earbuds in and was looking at a cell phone while checking a text message. Other cognitively intact residents reported that staff were on their phones frequently, including in hallways and while providing care, and that staff used phones and headphones during care encounters. Observations confirmed that one CNA sat texting on a cell phone in a hallway lounge with multiple residents present, and another CNA sat next to a resident on a couch wearing headphones and looking at a phone, and was later seen in the hallway wearing headphones and looking at the phone. During a resident council meeting, several residents reported prior concerns to administration about staff not treating residents in a dignified manner. They stated that care staff often entered rooms, turned off call lights while saying "I’m not your aide," and left without notifying another staff member that the resident needed care. Residents also reported that staff were often heard laughing, talking loudly, or yelling to one another on the halls during the night shift, and had been observed on their cell phones while providing care. Staff interviews, including with a CNA, an LPN, the Administrator, and the DON, confirmed that the facility’s expectation was that personal cell phones and headphones not be used in resident care areas and that cell phone use should be limited to the break room, underscoring that the observed and reported behaviors were inconsistent with facility policy and resident rights.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure food and beverages were served at safe and appetizing temperatures, as evidenced by multiple temperature measurements and resident interviews. The facility’s undated meal service temperature log required hot foods to be maintained at or above 135°F in the steam table and cold foods at or below 41°F. However, during a lunch observation on 4/8/26 in the memory care unit, soup measured 126.8°F and meatballs measured 129.3°F, both below the required hot-holding temperature. During a breakfast tray observation on 4/9/26 on the 300 hall, cream of wheat measured 80°F, scrambled eggs 109°F, and biscuits and gravy 111.1°F, all below the facility’s stated hot food standard. Interviews with cognitively intact residents further showed a pattern of food being served cold. One resident with COPD, muscle weakness, depression, and anxiety reported that food was always served cold. Another resident with dementia, muscle weakness, and quadriplegia stated that food was normally served cold when eaten in the room. A resident with muscle weakness, seizures, chronic kidney disease, and heart failure reported food was served cold most days. A resident with heart failure, diabetes, chronic kidney disease, and depression said room trays were normally served cold, and another resident with depression, anxiety, and high blood pressure stated the food was always served cold. The Dietary Supervisor, Administrator, and DON each stated they expected food to be served at safe and palatable temperatures, which was inconsistent with the observed temperatures and resident reports.
Dirty Wheelchairs, Stained Carpet, and Glue Trap Left in Common Area
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment by leaving the wheelchairs of two cognitively intact residents dirty and covered with thick amounts of dust, food particles, and hair on the wheelchair frames and wheels. One resident had diagnoses including heart failure, high blood pressure, and renal failure, and the other had diagnoses including heart failure, diabetes, and renal failure. Both residents were observed using their wheelchairs in their rooms and throughout the facility, and both stated that staff had never cleaned their wheelchairs. Facility staff gave inconsistent accounts of wheelchair cleaning practices, with one LPN stating there was no cleaning schedule and wheelchairs were wiped as needed, while a CNA said they were cleaned by night shift based on shower days and the DON said night shift was expected to clean them according to scheduled shower days. The facility also left a large maroon stain on the [NAME] Hall living room carpet after a resident fell and bled there, and the stain remained visible for several days during repeated observations. In addition, a pest control glue trap was observed sitting on folding tables in the windowed common area across from the Lodge therapy gym on multiple occasions. Staff interviews confirmed the stain had been present for days, the EVS Director was the only person responsible for carpet cleaning, and housekeeping staff acknowledged that glue traps should not be left on tables in resident common areas because it was not considered homelike. The Administrator and DON stated they would expect blood cleanup with a special cleaner and removal of glue traps from resident common areas.
Failure to Send Transfer and Discharge Notices to Ombudsman
Penalty
Summary
The facility failed to send copies of transfer and discharge notices to the representative of the Office of the State Long-Term Care Ombudsman for 11 out of 12 months reviewed. The facility’s Discharge and Transfer policy, last revised 9/17/25, required that a copy of a transfer or discharge notice be provided to the Ombudsman. Review of the admission and discharge report dated 6/26/24 through 4/6/26 showed 39 residents were discharged from the facility. Review of the Social Service Director’s monthly emails to the Ombudsman’s office showed no transfer or discharge notifications were sent in April 2025 through February 2026. During interview, the SSD stated she was aware she had missed a couple of months sending the transfer and discharge list and acknowledged it was her responsibility to send the information to the Ombudsman’s office. The Administrator stated she expected the SSD to send the required discharge and transfer documentation to the Ombudsman’s office.
Failure to Provide Resident Activities
Penalty
Summary
The facility failed to provide activities to meet residents’ needs, including one resident who was identified for one-on-one activities and two residents who reported that activities were not being provided. Resident #5 had severe cognitive impairment, was dependent on staff for multiple activities of daily living, and had diagnoses including depression, anxiety, heart failure, and kidney disease. The resident’s care plan called for one-to-one room visits and activities if unable to attend out-of-room activities, with preferred activities listed as pet visits. The facility’s activity documentation showed only one handwritten note describing a 15-minute conversation about the resident’s family and cat, and no further documentation of one-on-one visits was provided. The resident stated he/she was never brought out by staff for activities and would have liked to see the staff member’s dog again, and also said the TV had not been working consistently. Resident #3, who was cognitively intact and had diagnoses including COPD, muscle weakness, depression, and anxiety, stated there were not enough activities provided and that many of the activities felt babyish. Resident #140, who was also cognitively intact and had diagnoses including depression, anxiety, and hypertension, stated there were not enough activities and reported that staff told residents the activity department was short staffed, which was why activities were not being done. These interviews reflected that the residents were not receiving the level or type of activities they expected. Observations also showed that activities were not occurring on the 300 hallway during multiple times on separate days. In addition, the activity calendar for [NAME] Hall listed scheduled programs such as Morning [NAME], Nails and Tales, Morning Prayers, Noodle Balls, and Hungry Hippos, but observations showed residents sitting in front of the TV instead of participating in the scheduled activities. Staff interviews confirmed that activities were not occurring consistently on [NAME] Hall, that the hall needed more activity support for residents with behaviors and sundowning, and that the activity director was short-staffed and working in central supply, which affected completion of one-on-one and hallway activities.
Unsecured and Improperly Labeled Medications on Multiple Carts
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored securely and labeled in accordance with accepted professional principles. During observation, five medication and treatment carts were found with multiple problems, including unlocked carts, expired medications and supplies, unlabeled or improperly labeled items, and loose pills stored outside of packaging. The facility policy required medication carts to be locked when not attended, medications to be stored in the pharmacy-labeled container, and outdated or deteriorated medications to be removed from inventory. On the 400 Hall treatment cart, surveyors observed the cart unlocked with a Slim Jim meat stick, two Lantus insulin pens without an open date, another insulin pen with no identification or open date, multiple open liquid medications without open dates, a tube of diclofenac sodium with no patient label, and an open bottle of Miralax with no open date. On the 400 Hall CMT cart, the top drawer contained an unlabeled medication cup with a white pill, two blister packs of Zofran with no patient labels, a blister pack of loperamide with no patient label, hand lotion, an open container of pudding, eye drops without open dates, and the fourth drawer contained 18 loose pills of various sizes, colors, and shapes. The [NAME] Hall nurse cart was also unlocked and contained nitroglycerin with no patient name, expired needles, an expired culture swab, expired artificial tears, and unlabeled sore throat spray and loperamide. The [NAME] Hall treatment cart contained an open package of Xeroform with no label, zinc oxide ointments with no patient labels, and hydrophilic wound barrier cream with no patient label. The dementia unit cart contained expired glucometer control solution, a blister pack of risperidone with no patient label, six loose pills, and expired Systane eye drops. Staff interviews confirmed that open medications without dates should be discarded, carts should not be left unlocked, and carts should be free from clutter, pills, and expired supplies.
Infection Control During Feeding and Dirty Steam Table
Penalty
Summary
Staff failed to follow appropriate infection control practices while assisting a resident with feeding in the main dining room. Resident #12 had severe cognitive impairment and diagnoses that included aphasia, paraplegia, hemiplegia, hemiparesis, and dementia. During lunch observation, a CNA sat with the resident, scooped up soup, blew on the spoonful of soup, and fed it to the resident. The CNA continued blowing on the resident's soup spoon until the resident finished the soup. Later in the same meal, the CNA cut up the resident's meatballs and blew on the spoon before feeding the meatballs to the resident. The DON stated that staff were expected to set food aside if it was too hot to feed and that blowing on a resident's food was an infection control concern and should not be done. The facility also failed to ensure the [NAME] Hall steam table was clean. The daily cleaning schedule included cleaning and sanitizing prep tables, but observations showed the steam table had brown, dried, baked-on food around the steam wells, cloudy water with sediment floating in it, and cloudy splash guards with dried, crusted liquid on them. These conditions were observed on two separate occasions. A dietary aide stated the steam table was filthy, had already gotten in trouble for not cleaning it, and did not have enough time to clean it as it should be cleaned. A CNA said the steam tables had looked dirty for months. The Administrator and DON stated they expected the steam table on [NAME] Hall to be cleaned after every use.
Failure to Provide Timely Incontinence and Perineal Care
Penalty
Summary
The facility failed to provide timely and appropriate ADL care, specifically perineal care and toileting assistance, to a cognitively intact resident who was frequently incontinent of bowel and bladder and dependent on staff for toileting hygiene. The resident’s care plan directed staff to assist with bathroom use as desired, offer toileting before and after meals and at bedtime, and clean the perineum after each incontinent episode. On the survey day, the resident was heard yelling for a nurse from the hallway, reporting they had been calling for help for about 30 minutes because they needed to use the bathroom. The resident’s call light was wrapped around the bed frame and out of reach, preventing the resident from calling for assistance. Over the course of more than two hours of observation, the resident remained in bed with a strong odor of stool and later of both stool and urine, repeatedly stating they were soiled, wet, and had not been checked on. Staff did not enter the room to provide care until approximately 11:04 A.M., at which time a CNA and an LPN found the resident’s brief and bed pad saturated with urine and a large amount of diarrhea present. The resident stated they had not been changed all night or that morning. Facility staff, including an LPN, a CNA, and the DON, reported that incontinent residents were expected to be checked every one to two hours and to be kept clean, dry, and odor free, indicating that the observed delay of over two hours in responding to the resident’s needs and the condition in which the resident was found did not meet the facility’s stated expectations or policy for perineal care and incontinence management.
Lack of Orders and Monitoring for Family-Applied External Urinary Device
Penalty
Summary
The facility failed to ensure a resident using an external urinary collection device had appropriate physician orders, care instructions, and monitoring. The resident had moderate cognitive impairment, was always incontinent of bowel and bladder, and had diagnoses including stroke and neurogenic bladder. The resident’s MDS did not indicate use of an external or indwelling catheter, and the care plan only addressed bowel and bladder incontinence with interventions such as assisting to the bathroom and cleansing the peri-area after incontinence episodes. There was no care plan focus or interventions related to an external urinary drainage device, and the physician order sheet contained no orders for such a device. Surveyors observed a urinary drainage bag filled with yellow urine in a basin on the floor, with catheter tubing on the floor and a condom catheter attached and secured with grey duct tape. A CNA reported that the resident’s family member had been applying the condom catheter and duct tape every evening for over a month, and that the CNA removed it each morning, but did not empty the drainage bag, leaving that to the family member. Multiple LPNs, including those responsible for the resident’s care, stated they were unaware the resident was using a condom catheter at night and that a family member was securing it with duct tape. The DON also reported being unaware of the device’s use and expected that staff would have notified nursing so that documentation, skin checks, physician orders, monitoring, and family education related to the external urinary drainage device would occur, none of which had been done.
Medication Error Rate Above 5% Due to Improper Midodrine and Ophthalmic Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying an 11.11% error rate based on 3 errors out of 27 medication administration opportunities observed. One deficiency involved a resident with dementia, hearing loss, and hypotension whose care plan included hypotension management with medications as ordered and monitoring for side effects and effectiveness. The resident had an order for Midodrine 10 mg PO three times daily, but there was no corresponding order to check blood pressure prior to administration. During an observed medication pass, a certified medication technician (CMT) administered Midodrine without taking the resident’s blood pressure beforehand and stated they did not know what Midodrine was used for, later acknowledging they should have taken the blood pressure first. Another deficiency involved improper administration of ophthalmic medications to a resident with severely impaired cognition, maximal ADL assistance needs, and diagnoses including kidney disease, hypertension, Alzheimer’s disease, aphasia, and seizures. The resident had physician orders for Dorzolamide HCl-Timolol ophthalmic solution and Brimonidine Tartrate ophthalmic solution, both to be instilled in both eyes three times daily for glaucoma/ocular pressure, but the resident’s care plan did not address the need or reason for eye drops. The facility’s eye drop administration policy required specific technique, including forming a pouch in the lower eyelid, avoiding contact of the dropper tip with the eye, compressing the tear duct or keeping the eye closed, wiping excess solution, and waiting 10 minutes between different eye medications. During an observed eye drop administration, the same CMT pried the resident’s eyelids open while the resident resisted and instilled Brimonidine solution in both eyes, then immediately proceeded to administer Dorzolamide-Timolol solution without pausing between the two different medications. This technique did not follow the facility’s eye drop administration policy or the manufacturer’s instructions, which required a waiting period between different ophthalmic solutions. The DON stated an expectation that staff follow the eye drop administration policy, including hand hygiene, glove use, proper eyelid positioning, wiping excess solution, and pausing between different eye solutions.
Call Light Not Kept Within Resident Reach
Penalty
Summary
Reasonable accommodation of resident needs and preferences was not provided when a resident's call light was not kept within reach. The resident's quarterly MDS dated 3/24/26 showed the resident was cognitively intact, dependent on staff for toileting hygiene, frequently incontinent of bowel and bladder, and had diagnoses including Parkinson's disease, dementia, and COPD. The care plan directed staff to ensure the resident's call light was within reach and to encourage use of it for assistance as needed, with a prompt response to requests for help. During observations, the resident was heard yelling for a nurse from the hall and said he/she had been calling for about 30 minutes because he/she needed to use the bathroom. The resident was later observed with a strong odor of stool, then soiled and wet, and stated he/she could not reach the call light and needed help going to the bathroom and getting cleaned up. The call light was observed wrapped around the bed frame and out of reach on multiple occasions, and later tucked between the cushion of a recliner about two feet away from the resident. CNA X and LPN K stated the call light should be within the resident's reach at all times, and the DON stated all residents' call lights were expected to be within reach at all times.
Failure to Follow Physician Orders and Medication Administration Standards
Penalty
Summary
The facility failed to ensure services met professional standards of practice by not following a physician order for daily weights for a resident with CHF, HTN, and renal failure. The resident was cognitively intact and had a care plan intervention to check daily weight and fax a weekly log to the cardiac clinic. The physician order required daily weights and notification of the physician or NP for a weight gain of three pounds in 24 hours or five pounds in three days, but the weight record showed multiple missed daily weights in March and early April, and the resident stated staff did not weigh him/her daily. Staff interviews showed the night shift aides were expected to obtain the daily weights and give them to the nurse for documentation in the EMR. An LPN stated the nurses should document the weights in the EMR under the weight tab. The DON stated she expected staff to follow physician orders and obtain daily weights and that she was aware the resident had CHF and required daily weights. The facility also failed to ensure medications were administered by authorized staff for another resident with severe cognitive impairment who was dependent on staff for all ADLs and had Parkinson disease, diabetes, COPD, dysphagia, multiple pressure ulcers, and diabetes. The resident had orders for multiple medications, including metoprolol, gabapentin, tramadol, carbidopa-levodopa, divalproex, metformin, sertraline, and others, along with an order to crush/sprinkle all meds every shift. During observation, the resident's family member was feeding breakfast while a medicine cup containing crushed medications was left in the room with no staff present. A CMT stated the cup was handed to the family member to feed to the resident between bites of breakfast and that the staff member did not remain to see if the resident took the medication. The DON stated family members should never administer medications and that staff should remain at the resident's side if a prepared medication cup was provided to a family member.
Pressure ulcer care and prevention failures
Penalty
Summary
The facility failed to provide adequate pressure ulcer treatment and prevention for three residents. For one resident with a coccyx wound and pressure ulcer risk, the record showed an order for coccyx wound care with cleansing, calcium alginate, and bordered gauze each shift and as needed if soiled or nonintact, but the TAR showed one missed treatment out of 18 opportunities in March and two missed treatments out of 14 opportunities in April. The resident’s skin observation and progress notes documented worsening coccyx breakdown, tunneling, and later additional open areas, while the wound was described as painful and bleeding during observation. The resident also had a regular mattress, and the wound nurse noted the resident was followed by an outside wound clinic, with the wound care plan changing after the wound had already worsened. For another resident with multiple severe pressure ulcers, including stage 4 ulcers of the sacrum, left hip, and left lower back, the record showed ordered wound care with Dakin’s solution, gentamicin, Santyl for the hip, calcium alginate, bordered gauze, heel protectors, and turning every two hours. During observation, the resident’s low air loss mattress was set at 9, which staff identified as a setting for a 500-pound person, while the resident weighed 117 pounds. The resident had heavy drainage on the bedding, and several dressings were saturated, bulky, or dislodged. Staff observations also showed a blanket folded under the resident, fecal soiling, and compromised dressings with dried drainage visible. The wound nurse stated the mattress setting was too high and could risk the wounds getting worse, and the DON stated the facility did not have a specific low air mattress policy and was not monitoring settings before the survey. For a third resident at high risk for pressure injury due to quadriplegia, incontinence, and assistance needs for bed mobility, the record showed no physician order for air loss mattress usage or settings. Observations showed the resident’s mattress set to 320 with normal pressure on multiple occasions. The resident’s care plan identified the resident as at risk for pressure ulcer development and called for turning every two hours, but the survey findings documented that the mattress setting was not tied to a physician order and was being used without a documented resident-specific setting. The DON stated that physician orders should indicate firmness and that settings should be checked every shift, and the Medical Director stated staff should follow physician orders and facility policy.
Failure to Provide Appropriate Foot Care
Penalty
Summary
The facility failed to provide foot care and treatment in accordance with professional standards of practice for two residents. Resident #60 had severe cognitive impairment, was dependent on staff for footwear and bathing, and had diagnoses including stroke and high blood pressure. The resident’s care plan did not include foot care, and the physician order sheet showed an order for diabetic nail and foot care every week on nights, every Monday, but no order for a podiatry consult. The podiatrist appointment list did not include the resident. On observation, the resident was found in bed wearing tight black socks that left indentations in the ankles, with extremely dry feet, thick flakes of dry skin, and toenails that were long, thick, and curled over the toes. An LPN stated he/she had been providing weekly foot care by checking the heels and applying lotion without removing the socks and was not aware the toenails were long. Resident #98 was cognitively intact, required partial to moderate assistance with footwear, and had diagnoses including Parkinson’s disease, dementia, COPD, and diabetes. The resident’s care plan addressed diabetes and skin monitoring but did not address foot care. The physician order sheet had no order for a podiatry consult, and the podiatrist appointment list did not include the resident. During observation, the resident’s socks were removed and the feet were found to be extremely dry with thick flakes of skin falling off, and the toenails were thick and approximately 0.5 inches long. The resident stated he/she had not seen a podiatrist. Staff interviews showed CNAs were expected to clean feet, apply lotion, and report foot issues, while nurses were expected to identify foot problems during bathing and skin assessments and place residents on the podiatrist list as needed.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
Staff failed to use a gait belt during a transfer for a resident who required assistance. The facility's Gait Belt Transfer policy dated 10/22 stated that a gait belt would be used for residents who require one assist with transfers, and that staff should place and fasten the belt, ensure it is snug, and transfer the resident with a firm grip on the belt. The resident's quarterly MDS dated 3/24/26 showed the resident was cognitively intact, used a wheelchair, was dependent on staff for toileting hygiene, required partial to moderate assistance for sit-to-stand and bed-to-chair/chair-to-bed transfers, was frequently incontinent of bowel and bladder, and had diagnoses including Parkinson's disease, dementia, and COPD. The care plan in use at the time of survey identified an ADL performance deficit related to activity intolerance and directed transfers with one staff member assist. During observation on 4/6/26 at 11:04 A.M., the resident was found in bed with a strong odor of stool and urine. CNA DD and LPN K assisted with cleaning and dressing the resident, then placed the wheelchair beside the bed and instructed the resident to move to the side of the bed and stand. CNA DD held the resident under the left arm while the resident held onto the wheelchair with the right hand. The resident had difficulty standing upright and moving his/her feet. LPN K and CNA DD then held the back of the resident's pants and pivoted the resident into the wheelchair without using a gait belt. LPN K stated they messed up and acknowledged that a gait belt should have been used. CNA X later stated a gait belt was required anytime a resident needed help getting out of bed or a chair, and the DON stated staff were expected to use a gait belt on all residents who required assistance with transfers and ambulation.
Inaccurate Documentation of Wound Care and Oxygen Tubing Change
Penalty
Summary
The facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards when staff documented treatments as completed even though they had not been administered for one resident. The resident’s quarterly MDS dated 3/30/26 identified the resident as cognitively intact with diagnoses including dementia, muscle weakness, and quadriplegia. The physician’s orders included a wound treatment order for the right great toe, an order to change oxygen tubing weekly on Sunday evening shift, and an order for oxygen at 3 L via NC as needed. Review of the April 2026 TAR showed staff documented the right great toe wound treatment as completed on 4/2/26 and documented the oxygen tubing change as completed on 4/5/26. However, observation on 4/6/26 showed the resident’s oxygen tubing was dated 3/15/26, and observation on 4/7/26 showed the dressing on the right great toe was dated 3/26/26. During interview, the resident stated oxygen was used as needed and was unsure when the dressing had last been changed. An LPN stated the right great toe wound was healed and the dressing was being used as a preventative measure, but it should be changed per the physician’s orders. The Administrator stated there was no policy regarding medical record documentation accuracy, and later the Administrator and DON stated staff should not document treatments or orders as completed if they were not administered.
CNA In-Service Training Hours Not Ensured
Penalty
Summary
The facility failed to ensure Certified Nurse Aides (CNAs) employed for more than a year received no less than 12 hours of in-service training per year, affecting two of five sampled employees. The facility assessment dated 1/30/26 listed annual competency topics for staff, including ADLs, disaster planning, medication administration, measurements, resident assessment, caring for people with dementia and Alzheimer's disease, caring for people with mental and psychosocial disorders, non-pharmacological management of responsive behaviors, and caring for residents with trauma/PTSD, but it did not identify how many training hours were required annually for CNAs. Review of CNA EE's record showed a hire date of 7/18/17 and that on the first day of survey, 4/6/26, the CNA completed 15.5 hours of training between 4:25 P.M. and 6:20 P.M. Review of CNA FF's record showed a hire date of 9/1/24 and only 3.5 hours of training completed between 9/1/24 and 9/1/25. During interview, CNA N said CNAs receive training through an online portal and that facility administration sets courses to be completed, with CNAs expected to complete 12 hours of training per year from hire date to hire date. The DON and Administrator stated they expected all CNAs to receive 12 hours of continuing education yearly and that training should be completed gradually throughout the year rather than all in one day.
Failure to Provide Adequate Foot Care and Documentation
Penalty
Summary
The facility failed to ensure proper foot care for a resident, resulting in dry skin and a blister on the resident's left foot. The resident, who was cognitively intact and had diagnoses including vascular dementia, COPD, and CKD, had a physician's order for a head-to-toe skin assessment every Thursday and specific wound care for the left foot. However, there were no orders for lotion or preventive ointments for the resident's dry skin. Skin assessments and shower sheets did not document the resident's dry skin, and the care plan was not updated to address the blister or dry skin. Observations revealed that the resident's left foot had a reddened, raw area with blood and peeled skin, while the right foot had dry, flaky skin. Interviews with staff, including a CNA, LPN, and the DON, indicated awareness of the resident's foot wound and dry skin but a lack of documentation and treatment for the dry skin. The DON and Administrator were not aware of the dry skin issue, and the facility's skin integrity policy was not followed, leading to incomplete and inaccurate skin assessments and shower sheets.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report an allegation of injury of unknown origin to the Department of Health of Senior Services (DHSS) within the required two-hour time frame. A resident was found wandering onto another unit, wearing only a brief, with a cord tied around their waist and a bloodied face. Despite the serious nature of the injuries, which included a laceration on the forehead and nose, and bruising on the right side of the face, the incident was not reported to DHSS as an injury of unknown origin. The resident, who was admitted with diagnoses including atrial fibrillation, paranoia, anxiety, restlessness, agitation, history of falling, closed head injury, and dementia with behaviors, was extremely confused and had an unsteady gait. Staff members, including a CMT and a CNA, observed the resident with blood on their face and hands, but due to a language barrier, the resident could not explain what happened. The facility's investigation determined that the injuries most likely occurred due to a fall, but there was no documentation of the incident being reported to DHSS within the required time frame. Interviews with staff revealed that there was confusion about the nature of the incident, with some assuming it was a fall and others noting the seriousness of the injuries. The Administrator concluded the incident was an unwitnessed fall and did not expect staff to report it to DHSS. However, the lack of certainty about the cause of the injuries and the failure to report them as an injury of unknown origin constituted a deficiency in the facility's reporting procedures.
Failure to Maintain Licensed Administrator
Penalty
Summary
The facility failed to have a licensed Administrator responsible for establishing and implementing policies for managing and operating the facility, which had the potential to affect all residents. The issue arose when Administrator A's license expired, and the Director of Business Operations (DBO) had to step in temporarily. The DBO applied for a Temporary Emergency License (TEL) after Administrator A's last day at the facility, but there was a period between the expiration of Administrator A's license and the issuance of the TEL where the facility did not have a licensed Administrator. During this period, the DBO was on site and serving as the Administrator, although he was not licensed. The facility attempted to contract an Administrator, but the arrangement fell through, exacerbating the situation. Interviews with the Interim Administrator and the DBO revealed that there was confusion and a lack of clarity about who was serving as the Administrator during the gap, and the Interim Administrator expected the facility to adhere to regulations requiring a licensed Administrator.
Failure to Conduct NA Registry Checks for New Hires
Penalty
Summary
The facility failed to ensure that newly hired employees were screened for federal indicators of abuse, neglect, or misappropriation of resident property through the Nurse Aide (NA) Registry. This deficiency was identified for three out of ten sampled employees hired since the last survey, despite the facility having hired at least 57 new employees during this period. The facility's Abuse Prevention policy, approved in June 2022, mandates that all employees and volunteers be screened prior to working with residents, including verification of references, certification, license, and criminal background checks. However, the policy was not adhered to, as evidenced by the absence of NA registry checks in the employee files of Employees A, B, and C. Interviews conducted during the survey revealed a lack of awareness and understanding of the requirement to conduct NA registry checks. The Human Resources representative indicated that background checks were completed and stored at the regional office but was uncertain if NA registry checks were necessary for non-nursing staff. The Administrator confirmed that NA registry checks were not performed and was unaware that such checks should have been conducted for non-nursing staff. This oversight in the screening process potentially compromised the safety and well-being of the residents, as the facility did not fully implement its abuse prevention policy.
Failure to Provide Bedtime Snacks
Penalty
Summary
The facility failed to provide and offer snacks at bedtime, as snacks were only offered mid-day between lunch and dinner. This deficiency was identified through observations and interviews with staff and residents. The Dietary Manager confirmed that meals were served at specific times, with breakfast at 7:30 A.M., lunch at 12:30 P.M., and dinner at 5:30 P.M. However, residents reported that snacks were not offered after dinner, and one resident mentioned experiencing low blood sugar at night, which was only addressed with pudding. The Activity Director stated that snacks were distributed at 3:00 P.M. during an event called [NAME], but no snacks were routinely offered after dinner unless requested by residents from CNAs. Further investigation revealed that snacks were stored in cabinets by the nurse's station, but only staff were aware of their location. Observations showed that the [NAME] Hall refrigerator contained only health shakes, and the storage cabinets had no snacks. The Dietary Manager mentioned that the dietary department attempted to stock each nursing station every other day, but there was uncertainty about whether snacks were being refilled or if staff and residents were receiving them. The Director of Nursing stated that snacks were supposed to be available after dinner/bedtime, but the current practice did not ensure this availability.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by multiple observations of staff not following established protocols. Staff were observed bringing a treatment cart into an isolation room without cleaning and disinfecting it before moving it to another resident's room. Additionally, during wound care for a resident, staff did not perform hand hygiene between glove changes, failed to disinfect a clean field, and did not sanitize scissors used in the procedure. These actions were contrary to the facility's policies on transmission-based precautions and wound care procedures. Several residents were affected by the facility's failure to implement enhanced barrier precautions (EBP) appropriately. Staff did not wear the required personal protective equipment (PPE) during high-contact activities with residents who had multidrug-resistant organisms or chronic wounds. For instance, a resident with a urinary catheter and another with a PICC line did not receive care with the necessary gown and gloves, as mandated by the facility's EBP policy. The lack of proper signage and communication about isolation and EBP status further contributed to the lapses in infection control. Interviews with facility staff, including the Administrator and Director of Nursing, revealed an expectation for adherence to CDC guidelines and facility policies. However, observations indicated a disconnect between these expectations and actual practices. Staff were not consistently following procedures for cleaning equipment, performing hand hygiene, and using PPE, which are critical components of infection prevention and control in a healthcare setting.
Failure to Notify Physician of Resident's Condition Changes
Penalty
Summary
The facility failed to notify a resident's physician in a timely manner when there was a change in the drainage from a surgical wound and a change in the resident's blood pressure. The resident, who was alert and oriented, had a history of dependence on renal dialysis and a right hip fracture with intramedullary nailing. The resident's care plan included monitoring the surgical site for signs of infection and reporting any changes to the medical doctor. However, the facility did not adhere to its Clinical Protocol for notifying healthcare providers of clinical problems. The resident experienced purulent drainage from the surgical wound, elevated temperature, and low blood pressure over several days. Despite these significant changes, there was a lack of communication between shifts, and the physician was not notified promptly. The night nurse documented the resident's condition but failed to ensure that the day nurse contacted the physician. The resident's blood pressure readings were consistently low, and the surgical site showed signs of infection, yet these issues were not communicated effectively to the attending physician or the orthopedic surgeon. Interviews with nursing staff revealed inconsistencies in reporting and documentation practices. Some nurses did not receive complete reports from the previous shift, and there was confusion about whether the physician had been notified. The Director of Nursing and Administrator expected staff to notify the physician immediately in case of a change in condition, but this did not occur. The failure to notify the physician in a timely manner resulted in a delay in addressing the resident's medical needs, as evidenced by the eventual decision to send the resident to the emergency room.
Medication Mismanagement and Delayed Hospital Transfer
Penalty
Summary
The facility failed to meet professional service standards by not clarifying medication orders and documenting the same medication in multiple forms, leading to duplicated doses for a resident diagnosed with Alzheimer's disease, unspecified dementia, and GERD. The resident had conflicting orders for pantoprazole, with both tablet and suspension forms being documented as administered. Interviews with LPNs revealed uncertainty about the last administration date due to expired medication and duplicate orders in the electronic system, which had been down for over a month. The Medical Director confirmed the correct order and emphasized the need for staff to verify duplicate orders before administration. Additionally, the facility did not follow physician orders for another resident who required timely hospital transfer due to a dehisced surgical incision with signs of infection. Despite the physician's orders to send the resident to the hospital, the transfer was delayed. Interviews with nursing staff revealed communication lapses and task delegation issues, resulting in the resident remaining at the facility longer than necessary. The DON and Administrator expressed expectations for timely assessment and transfer following physician orders, which were not met in this case. The report highlights significant deficiencies in medication management and adherence to physician orders, impacting resident care. The facility's failure to address duplicate medication orders and ensure timely hospital transfers for residents with urgent medical needs demonstrates a lack of compliance with professional standards and facility policies.
Failure to Implement Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to adhere to its policy regarding the administration of PRN psychotropic medications, specifically for a resident with moderately impaired cognition and behaviors such as rejection of care and wandering. The resident, who had diagnoses including stroke, dementia, and malnutrition, was prescribed Lorazepam, an antianxiety medication, on an as-needed basis without a specified stop date. The facility's policy mandates that PRN psychotropic medications should have a stop date of 14 days or less unless a practitioner documents the rationale for an extended order. However, the order for Lorazepam did not include an end date, and the medication was administered multiple times over a three-month period without reevaluation or reordering. Interviews with the Director of Nursing and the administrator confirmed that the facility's standard practice is to have a 14-day stop date for PRN antianxiety medications, with a requirement for reevaluation and reorder. Despite this policy, the resident's PRN Lorazepam order lacked a stop date, indicating a failure in the facility's medication management practices. This oversight was identified during a survey, highlighting a deficiency in the facility's compliance with its own policies and federal regulations regarding the use of psychotropic medications.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals, as observed during a survey. Three out of five medication carts and both medication rooms were inspected, revealing issues in the medication room refrigerators. An expired bottle of Pantoprazole suspension, used for treating heartburn, was found in the medication storage refrigerator for a resident. Additionally, an opened vial of tuberculin purified protein derivative (PPD) solution was not dated, which is necessary to track its usability period. The facility's policies on medication storage and disposal were not adhered to, as evidenced by the expired medications not being discarded and the lack of proper dating on opened medications. The facility's Storage of Medications policy requires nursing associates to maintain medication areas in a clean, safe, and sanitary manner, and to dispose of discontinued or outdated drugs. However, the staff failed to follow these guidelines, as demonstrated by the expired Pantoprazole and undated PPD vial. Furthermore, the facility did not maintain accurate temperature logs for the medication refrigerators. The temperature logs for May and June showed several missing entries and instances where temperatures were out of the acceptable range. Interviews with staff revealed that night shift nurses were responsible for logging refrigerator temperatures, but this was not consistently done. The Administrator was unaware of the missing logs and expected staff to discard expired medications, date opened medications, and log refrigerator temperatures daily.
Survey Results Not Accessible to Residents and Visitors
Penalty
Summary
The facility failed to make the results of the most recent survey and complaint investigations readily accessible to residents, family members, legal representatives, and visitors. Observations on multiple dates revealed that no survey results were displayed at the entrance, lobby, or receptionist desk, and there were no signs indicating their location. During a group interview, residents expressed their inability to locate the survey binder. When residents requested the binder from the receptionist, it could not be found, and the receptionist was unaware of its location, suggesting it might be in a storage room due to lobby construction. The Assistant Director of Nursing and the Administrator both acknowledged that the binder was typically kept in the front lobby but were unsure of its current whereabouts.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Saint Louis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lemay Nursing | 1.6 mi | ★★★★★ | 0 | 0 |
| Bluebird Wellness And Rehabilitation | 1.7 mi | ★★★★★ | 2 | 0 |
| Nazareth Living Center | 3.3 mi | ★★★★★ | 4 | 0 |
| Mary, Queen And Mother Center | 3.3 mi | ★★★★★ | 3 | 0 |
| St Louis Altenheim | 4 mi | — | 20 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.